A nurse in the respiratory unit is caring for client who has a past medical history of heart failure and is currently admitted for asthma exacerbation. When reviewing the provider's orders further clarification is needed for which of the following medications?

Barrel chest: Expected Finding

Increased fatigue: Finding to be reported to the provider

Respiratory rate 40 bpm: Finding to be reported to the provider

Thin appearance: Expected Finding

Rationales:

Barrel chest – Expected Finding:

A barrel chest is a common physical finding in clients with chronic obstructive pulmonary disease (COPD), especially emphysema. It results from hyperinflation of the lungs over time, altering the shape of the chest wall.

Increased fatigue – Finding to be reported to the provider:

While COPD clients often experience fatigue, a sudden or unusual increase in fatigue may indicate worsening respiratory function or exacerbation of the disease. This finding requires further assessment and possible intervention to prevent complications.

Respiratory rate 40 bpm – Finding to be reported to the provider:

A respiratory rate of 40 bpm indicates significant tachypnea and respiratory distress. This finding, coupled with accessory muscle use, suggests the client may be experiencing an acute exacerbation of COPD or impending respiratory failure, which requires immediate provider notification.

Thin appearance – Expected Finding:

Clients with COPD often have a thin or cachectic appearance due to increased energy expenditure for breathing and reduced caloric intake. This is a typical finding in advanced COPD and does not require urgent reporting unless accompanied by other concerning symptoms.

A) Retake the vital signs:
While taking vital signs is important, the client’s vital signs (respiratory rate of 13 bpm, oxygen saturation of 92%, and normal skin color) suggest that there is no immediate crisis, such as a sudden drop in oxygen saturation or significant hemodynamic instability. Therefore, retaking the vital signs would not address the most urgent issue at the moment, which is the client's shortness of breath while laying down.

B) Call the healthcare provider:
Calling the healthcare provider may eventually be necessary if the patient's condition worsens or remains unrelieved after interventions. However, the first priority should be to manage the client’s immediate symptoms and improve their comfort. The client’s complaint of shortness of breath when lying down suggests that the positioning may be a contributing factor to their discomfort.

C) Place the client in Fowler's position:
The most appropriate first action for a client with end-stage COPD and shortness of breath while lying down is to place the client in Fowler's position. This position (sitting upright, typically at a 45-60° angle) helps to improve lung expansion and reduce the workload of breathing by using gravity to assist in lung ventilation. It also promotes diaphragmatic breathing, which can relieve the feeling of breathlessness.

D) Increase the oxygen rate:
The client is already on 6 liters of oxygen via nasal cannula and has an oxygen saturation of 92%, which is within an acceptable range for a patient with COPD. Increasing the oxygen rate further could risk causing oxygen toxicity or lead to CO2 retention in clients with COPD, as their respiratory drive is often driven by low oxygen levels rather than high carbon dioxide levels. Thus, increasing the oxygen rate should be done cautiously and only if clinically indicated by a healthcare provider.